PULMONARY SURGERY

Dr. Tarpan Shah. MPT (CPD&ICU care),(DNHE)Vice-Principal &Asst.ProfShree Swaminarayan Physiotherapy college

• Lung surgery is the surgery to repair or remove lung tissue

• Biopsy of an unknown growth• Lobectomy• Lung transplant• Pneumonectomy• Surgery to prevent the build up or return of

fluid to the chest (pleurodesis)

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• Surgery to remove an infection or blood in the chest cavity(empyema)

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• General anaesthesia given• Pt will be be asleep and not felt any pain• Two common ways thoracotomy and video

assisted thoracoscopic surgery(VATS)• Thoracotomy means open surgery• Risks in surgey---• Allergic reactions to medicines• Breathing problems

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• Bleeding• Blood clots• Infection• Failure of lung to expand• Injury to the lungs• Pain

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• Prognosis---• Depends on• Type of problem being treated• How much of the lung is removed• Overall health before surgery

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INDICATIONS FOR SURGERY• Commonest is bronchial carcinoma1.Malignancy- primary bronchial carcinoma,

isolated secondaries arising from kidney or large intestine

2.Inflammatory- lung resection is required occasionally for lung abscess, tuberculosis , bronchiectasis

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3.Trauma- stab wounds, gun shot wounds

4.Degerative- large bullae in selected patients where there is compression of normal lung

5.Congenital- lobar emphysema

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Incisions

A)Lateral incision

1) Posterolateral incision:- this follow the vertebral border of scapula and line of rib 5th 6th 7th 8th to anterior angle of costal margin

Muscles cut are:- trapezius, LD, serratus anterior, rhomboids, intercostals, erector spinae

This incision is used for the lung operation

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2) Antero-lateral incision:- this start at middle of the anterior chest up to the posterior axillary fold.

Muscles cut are:- pectoralis major and minor, serratus anterior, intercostals.

This incision is used for mitral valvotomy and pleurectomy.

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B) Anterior incision1) Transverse:- this passes across the one side of

the 4th IC space to the other. Muscles cut are:- pectoralis major,

intercostals.2) Vertical incision:- splitting of the sternum

down the middle NO MUSCLE CUT This incision is used for open heart surgery.

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Types of operation

1) Pneumonectomy

2) lobectomy

3) Segmental or wedge resection

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Complication of surgery

1) Respiratory

- infection of the lung

- consolidation / collapsed

- pneumothorax

- broncho-pleural fistula

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BRONCHOPLEURAL FISTULA

• It implies breakdown of the bronchial stump and it occcurs around the 10 th postoperative day ,if small it may not be noticed untill much later

• It is recognised by dyspnea ,an irritating cough and possible expectoration of dark fluid

• The patient should be sat up or turned on to the operated side to prevent spill over of infected fluid in to the remaining lung

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2) Circulatory:- DVT Cardiac arrhythmia Haemorrhage3) Wound:- Infection Failure to heal Adherent scar4) Joint stiffness:- Sh joint Thoracic spine Costo-vertebral joints

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5) Muscle weakness:- LD Serratus anterior leg muscle if unexercised other divided muscles

6) Postural deformity:- forward or sideward bending

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Pneumonectomy

• Removal of entire lung• Radical Pneumonectomy along with that of entire lung

mediastinal gland is also removed.Complication:- • Damage to phrenic nerve • Damage to recurrent laryngeal nerve

Indication:- Carcinoma, bronchiectasis,

tuberculosis incision is posterolateral incision

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Preoperative physiotherapy

• Gain the confidence of patient• Clear the lung field• Breathing exercise• Postural awareness• Teach arm, trunk, leg exercise• Splinting of incision during coughing• Bed mobility

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Postoperative chest physiotherapy• Clear the lung field• Reexpansion of the lung• Prevent circulatory complication• Prevent wound complication• Regain the arm and trunk movement• Maintain the good posture• Conditioning exercise

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Key points

• Breathing exercises should be started on the day of surgery if possible.

• ACBT to remove the secretion and restore the lung volumes and capacities

• Adequate wound support for huffing and coughing should be taught.

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• Early mobilization progressing to stair

Climbing on third day postoperatively

• Exercise using a bicycle ergometer

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• Tracheal deviation- result into ineffective cough production

• Huffing rather than coughing is emphasized because of less chances of increase in intrathoracic pressure

• If suctioning is required than take care of stump.

• Breathing control with stair climbing may increase exercise tolerance.

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Splinting

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lobectomy

• Indication • Bronchiectasis• Tuberculosis• Lung abscess• Carcinoma

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Day of operation

• Half lying• Breathing exercise to expand the whole lung• Vibration over unoperated side• Huffing with splinting• Foot or ankle exercise

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Day – 1 ( 3- 4 session)

• Analgesia to reduce the pain so pt will cooperate in treatment

• Nebulizer therapy or humidification therapy• Breathing exercise with inspiratory hold• Side lying on unoperated side• Chest expansion exercise on remaining side• Postural drainage

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• Exercise of arm• Assisted arm elevation• Assisted arm movement in functional pattern• Neck exercise

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• Exercise for leg• Foot and ankle exercise• Quadriceps contraction• Hip and knee bending exercise

Start ambulation

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Day-2

• Self supported splinting• Chest expansion exercise• Breathing exercise• Unoperated side positioning• Arm as well as leg exercise• Start trunk exercise• Discourage the pt for crossleg sitting it will occlude

popliteal artery and can result into DVT

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Day 3- 4

• Arm and trunk exercise should continue• Increase the walking distance• Stair climbing• Group therapy• Aerobic exercise

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• Discharge at 10-12 days of post op• Home exercise programme• Aerobic exercise ( hyper Chest expansion

exercise• Ventilatory muscle training

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• Pain. Extrapleural bupivicaine infusion is an increasingly popular method of pain control following a thoracotomy.• Bronchial secretions. The appropriate timing and selection of minitracheotomy can help reduce

the incidence of sputum retention.• Pneumonia is a serious complication with a high mortality rate.

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• Atrial fibrillation is common with extensive resection in the elderly. Onset is usually 2-5

days postoperatively.• Wound infection • Haemorrhage. Significant bleeding, usually involving the bronchial arteries, occurs in 1-2%

of patients. It is more likely after a pneumonectomy.

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SEGMENTAL RESECTION

• A bronchopulmonary segment is removed with its segmental artery and bronchus

• Used for tuberculosis

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WEDGE RESECTION• This non anatomical resection is used for

diagnosis in open lung biopsy and treatment of well localised peripheral carcinomas in patients with redused lung function

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Thoracoplasty

• This operation is performed to produce the permanent collapse of a lung.

• This operation is performed in TB and emphysema.– Complication: deformity paradoxical breathing

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Pleural surgery1) Pleurectomy: is removal of parietal layer of

pleura e.g. pneumothorax -Visceral layer pleura stick with the chest wall2) Pleurodesis: insertion of powder into the

pleural cavity, which act as a irritants. - Position the pt in 10 min for each position - Expansion breathing exercise is performed in

each position.

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• 3) Decortication : - stripping of the two layer of pleura that

have become adherent with eachother.• E.g. empyema

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